Aircraft Accident Investigation Reports: Flight SQ006

29th Apr 2002

Singapore Airlines (SIA) has received copies of two reports on the accident that happened in Taipei on 31 October 2000. One report is by Taiwan`s Aviation Safety Council (ASC) and the other by a Singapore investigation team, headed by the Ministry of Transport (MOT).

When read together, these reports provide a comprehensive analysis of the accident. They conclude that it could have been the result of several contributing factors involving the flight crew, the air traffic controllers and the airport, as well as the weather conditions.

SIA accepts generally the findings of fact in these two reports; however, we disagree with some of the conclusions drawn in the ASC report.

It has always been clear that the aircraft took off from the wrong runway, but it appears that the ASC report does not give due weight to the deficiencies found at Chiang Kai Shek (CKS) Airport. We believe these deficiencies misled the pilots into taking off from the wrong runway.

We would like to highlight below some of the deficiencies at CKS Airport as mentioned in the two reports.

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á Runway 05R, which was being converted into a taxiway, had not been properly marked or closed. There were no barriers, markings or other visual warnings to prevent an aircraft from entering this runway. If barriers had been erected, or a white cross painted on the runway as required by the International Civil Aviation Organization (ICAO), the accident may not have happened.

á Instead, Runway 05R was prominently lit and marked as if it were an operational runway. The lights leading from the taxiway onto Runway 05R were also prominently lit and spaced 7.5 metres apart. In contrast, the taxiway lights leading to Runway 05L were, contrary to ICAO standards, spaced several times further apart, and not all of them were working. Consequently, the crew could see only the taxiway lights leading on to 05R.

á The air traffic controllers cleared the flight for take-off at the critical moment that it was taxiing towards Runway 05R. This reinforced the crew`s belief that they were entering the correct runway. In low visibility conditions, air traffic controllers at CKS Airport are required to determine the position of the aircraft before issuing take-off clearances. They did not follow this procedure.
The ASC report makes particular mention of the para visual display (PVD). According to the report, the PVD should have provided a cue that the aircraft was not on Runway 05L. We wish to explain that the PVD, which is installed by very few airlines, is not designed to warn pilots that they are on the wrong runway. It is a secondary aid, meant to help the pilot track the runway centreline if he cannot see it clearly. As the captain was able to see the runway centreline, he had no reason to refer to the PVD.

Following the accident, we studied the information available at that time to help us understand how it could have happened. We wanted to make sure that everything was being done to prevent this type of accident from happening again.

We traced the events leading up to the collision with construction equipment and reviewed all of our systems, procedures and practices. While we found that our practices were in line with generally accepted best practices in the industry at that time, we explored what more could be done.

For example, we have enhanced our take-off procedures to require all crew in the cockpit to visually confirm the correct runway designation before commencing take-off. We have also introduced a new module as part of our Crew Resource Management training to focus specifically on situational awareness.

Since the accident, we have also pressed manufacturers to develop new safety systems to prevent misidentification of runways and taxiways. We are the first airline to have placed an order for a newly-designed Boeing system to warn pilots if they are on the wrong runway.

We are committed to doing everything possible to prevent this type of accident in the future. We will study the recommendations in the ASC and the MOT reports in more detail, and we will implement any recommendations that would further enhance safety.